• Acute medical assessment units: an efficient alternative to in-hospital acute medical care.

      Watts, M; Powys, L; Hora, C O; Kinsella, S; Saunders, J; Reid, L; Finucane, P; Department of Medicine, Mid-Western Regional Hospital, Dooradoyle, Limerick. michael.watts@hse.ie (Irish Medical Journal, 2011-02)
      Acute Medical Assessment Units (AMAUs) are being proposed as an alternative to congested Emergency Departments (EDs for the assessment of patients with a range of acute medical problems. We retrospectively reviewed the discharge destination of patients referred to a newly established AMAU during a six-month period. During the same period we contrasted activity in the ED for a similar group of patients. 1,562 patients were assessed in the AMAU. 196 (12.5%) were admitted to an in-patient bed and 1,148 (73.5%) were entered into specific diagnosis-driven out-patient pathways. 1,465 patients attended the ED and 635 (43.3%) were admitted. Out-patient alternatives to expensive in-patient care need to be provided at the 'coal face" of acute referral. The AMAU provides this, and as a consequence admission rates are relatively low. This is achieved by directly communicating with GPs, accessing senior clinical decision makers, and providing immediate access to diagnostically driven outpatient pathways.
    • Acute stroke unit improves stroke management-four years on from INASC.

      Shanahan, E; Keenan, R; Cunningham, N; O'Malley, G; O'Connor, M; Lyons, D; Peters, C (Irish Medical Journal, 2015-02)
      The Irish Heart Foundation carried out the Irish National Audit of Stroke Care (INASC) in 2008. Management practices were significantly poorer than those in the UK Sentinel audits. Since then an acute stroke unit has been established in University Hospital Limerick. A stroke database was established. 12 key indicators of stroke management audited by INASC were identified. Results were compared to those in INASC. 89 stroke patients were admitted. 8 of the 12 key indicators scored significantly better than in INASC. 92.5% had a brain scan within 24hrs (INASC-40%, p = < 0.001). 100% of ischaemic strokes received anti-thrombotics (INASC-85%, p = 0.001). 94% had rehab goals agreed by MDT (22% in INASC p = 0.0000). 55% were treated in stroke unit (2% in INASC, p = 0.0000). MDT input improved with regard to physiotherapy (87% vs 43% in INASC, p = < 0.02) and SALT (74% vs 26%, p = < 0.02). Stroke management has significantly improved from 2008, however some deficiencies remain.
    • Acute type II cryoglobulinaemic vasculitis mimicking atherosclerotic peripheral vascular disease.

      Saeed, A; Khan, M; Irwin, S; Fraser, A; Mid Western Regional Hospital, Limerick, Ireland. modelian@gmail.com (2012-01-31)
      Atherosclerotic peripheral vascular disease is a common presenting cause for digital ischaemia in life long smokers. Acute severe Type II Cryoglobulinaemic vasculitis is a rare yet important cause, which may present with similar clinical features and which if undiagnosed may be rapidly fatal. Following the instigation of therapy with intravenous methylprednisolone and cyclophosphamide this patient made an excellent recovery.
    • Advanced and rapidly progressing head and neck cancer: good palliation following intralesional bleomycin.

      Quintyne, Keith Ian; Baker, Shirley; Wallis, Fintan; Shine, Neville; Gupta, Rajnish; Department of Medical Oncology, Mid-Western Regional Hospital, Limerick, Ireland. keithi.quintyne@hse.ie (2011-09)
      The authors herein report the case of a 61-year-old man undergoing adjuvant therapy for locally advanced laryngeal cancer, who developed parastomal recurrence in his radiation field around his tracheotomy site, while he was undergoing radiation therapy, and compromised the secure placement of his tracheotomy tube and maintenance of his upper airway. MRI restaging and biopsy confirmed recurrence and progressive disease in his mediastinum. He underwent local therapy with intralesional bleomycin with good palliation, and ability to maintain the patency of his upper airway.
    • Adverse event recording post hip fracture surgery

      Doody, K; Mohamed, KMS; Butler, A; Street, J; Lenehan, B (Irish Medical Journal (IMJ), 2013)
      Accurate recording of adverse events post hip fracture surgery is vital for planning and allocating resources. The purpose of this study was to compare adverse events recorded prospectively at point of care with adverse recorded by the Hospital In-Patient Enquiry (HIPE) System. The study examined a two month period from August to September 2011 at University Hospital Limerick. Out of a sample size of 39, there were 7 males (17.9%) and 32 females (82.1%) with an age range of between 53 and 98 years. The mean age was 80.5 years. 55 adverse events were recorded, in contrast to the HIPE record of 13 (23.6%) adverse events. The most common complications included constipation 10 (18.2%), anaemia 8 (14.5%), urinary retention 8 (14.5%), pneumonia 5 (9.1%) and delirium 5 (9.1%). Of the female cohort, 24 (68.8%) suffered an adverse event, while only 4 (57%) males suffered an adverse event.
    • Alopecia universalis, hypothyroidism and pituitary hyperplasia: polyglandular autoimmune syndrome III in a patient in remission from treated Hodgkin lymphoma.

      Quintyne, K I; Barratt, N; O'Donoghue, L; Wallis, F; Gupta, R K; Medical Oncology, Mid-Western Cancer Centre, Mid-Western Regional Hospital, Limerick, Ireland. keithi.quintyne@hse.ie (BMJ case reports, 2010-10)
      We herein report a case of a 33-year-old man in remission from Hodgkin lymphoma, who presented with reduced potency and hair loss. Initial endocrine tests revealed autoimmune hypothyroidism. An MRI of his pituitary gland at onset revealed hyperplasia. He tolerated replacement endocrine therapy with good response, but with no improvement in his alopecia universalis. A repeat MRI, 6 months after his initial endocrine manipulation, showed resolution of his pituitary hyperplasia.
    • Analysis of inpatient dermatologic referrals: insight into the educational needs of trainee doctors.

      Ahmad, K; Ramsay, B; Mid Western Regional Hospital, Dooradoyle Road, Limerick, Ireland., kashifaa2002@gmail.com (2012-01-31)
      AIM: To analyse inpatient consultation referrals to the Dermatology Department and to identify the educational needs of junior/trainee doctors. METHODS: Consultation data of inpatients referred to the Dermatology Department between 2001 and 2006 was reviewed. RESULTS: There were 703 referrals identified. Patients were referred from all wards in the hospital. There were a total of 113 different dermatological diagnoses in the group. One-fifth (22%) consultations were for skin infections, 12% had atopic dermatitis, 8% had psoriasis and 8% had clear or suspected drug cause for their rash. In 391 cases, the Consultant Dermatologist's diagnosis was different to the inpatient referral diagnosis on the consultation referral form. CONCLUSIONS: Our results emphasise the need for junior dermatology trainees to undertake extra training in both the dermatologic conditions. This data supports the need for expansion of service provision of dermatology in the region.
    • An anatomical study of the parasacral block using magnetic resonance imaging of healthy volunteers.

      O'Connor, Maeve; Coleman, Margaret; Wallis, Fintan; Harmon, Dominic; Department of Anesthesia and Intensive Care Medicine, Mid-Western Regional, Hospital, Dooradoyle, Limerick, Ireland. (2012-01-31)
      BACKGROUND: The parasacral approach to sciatic blockade is reported to be easy to learn and perform, with a high success rate and few complications. METHODS: Using magnetic resonance imaging, we evaluated the accuracy of a simulated needle (perpendicular to skin) in contacting the sacral plexus with this approach in 10 volunteers. Intrapelvic structures encountered during the simulated parasacral blocks were also recorded. RESULTS: The sacral plexus was contacted by the simulated needle in 4 of the 10 volunteers, and the sciatic nerve itself in one volunteer. The plexus was accurately located adjacent to a variety of visceral structures, including small bowel, blood vessels, and ovary. In the remaining five volunteers (in whom the plexus was not contacted on first needle pass), small bowel, rectum, blood vessels, seminal vesicles, and bony structures were encountered. Historically, when plexus is not encountered, readjustment of the needle insertion point more caudally has been recommended. We found that such an adjustment resulted in simulated perforation of intrapelvic organs or the perianal fossa. CONCLUSIONS: These findings question the reliability of the anatomical landmarks of the parasacral block and raise the possibility of frequent visceral puncture using this technique.
    • Anatomy of the ward round.

      O'Hare, James A; Department of Medicine, Mid-Western Regional Hospital, Dooradoyle, Limerick, National University of Ireland (Cork), Ireland. james.ohare@HSE.ie (European journal of internal medicine, 2008-07)
      The ward round has been a central activity of hospital life for hundreds of years. It is hardly mentioned in textbooks. The ward round is a parade through the hospital of professionals where most decision making concerning patient care is made. However the traditional format may be intimidating for patients and inadequate for communication. The round provides an opportunity for the multi-disciplinary team to listen to the patient's narrative and jointly interpret his concerns. From this unfolds diagnosis, management plans, prognosis formation and the opportunity to explore social, psychological, rehabilitation and placement issues. Physical examination of the patient at the bedside still remains important. It has been a tradition to discuss the patient at the bedside but sensitive matters especially of uncertainty may better be discussed elsewhere. The senior doctor as round leader must seek the input of nursing whose observations may be under-appreciated due to traditional professional hierarchy. Reductions in the working hours of junior doctors and shortened length of stay have reduced continuity of patient care. This increases the importance of senior staff in ensuring continuity of care and the need for the joint round as the focus of optimal decision making. The traditional round incorporates teaching but patient's right to privacy and their preferences must be respected. The quality and form of the clinical note is underreported but the electronic record is slow to being accepted. The traditional multi-disciplinary round is disappearing in some centres. This may be regrettable. The anatomy and optimal functioning of the ward round deserves scientific scrutiny and experimentation.
    • Annular Rupture During Transcatheter Aortic Valve Implantation: Predictors, Management and Outcomes.

      Coughlan, J J; Kiernan, Thomas; Mylotte, Darren; Arnous, Samer (International Cardiology Review, 2018-09-01)
      Transcatheter aortic valve implantation (TAVI) is the treatment of choice in patients with symptomatic severe aortic stenosis who are either inoperable or at high risk for conventional surgical aortic valve replacement. Recent data have also shown favourable outcomes in patients deemed to be at intermediate operative risk, which expands the application of this novel technology. Despite its success, TAVI has been associated with rare life-threatening complications. Of these, aortic annular rupture is considered to be the most devastating. Advances in pre-procedural screening and patient selection have reduced the incidence of annular rupture. When this complication occurs, early recognition and prompt management are essential. This article is intended to provide a comprehensive review of the predictors, management and clinical outcomes of aortic annular rupture.
    • Another string.... but no bow.

      Green, Connor; Molony, Diarmuid; Cashman, James; Burke, Tom; Masterson, Eric; Department of Trauma and Orthopaedics, Croom Orthopaedic Hospital, Co. Limerick, Ireland. connorjgreen@gmail.com (2011-04)
      Based on a positive personal experience, the authors advocate the use of a wound protector/retractor such as the Alexis system in total hip arthroplasty, to avoid intra-operative bacterial contamination from the skin, while avoiding damage to the skin and other soft tissues.
    • An assessment of the utility of unselected coagulation screening in general hospital practice.

      McHugh, Johnny; Holt, Carloyn; O'Keeffe, Denis; Department of Haematology, Mid Western Regional Hospital, Limerick, Ireland. mchughjohnny@gmail.com (2011-03)
      Coagulation screening using prothrombin time (PT) and activated partial thromboplastin time (APTT) is widely used. We performed an audit of coagulation screening in an Irish teaching hospital. We analysed PT and/or APTT results received during normal working hours during a 1-week period in our hospital. Abnormal results due to anticoagulants were excluded from further study. In samples with PT longer than 15.5 s and/or APTT longer than 42 s, we proceeded to 1: 1 mixing studies if the PT was prolonged and 1: 1 mixing studies, factor XII assay and lupus screen if the APTT was prolonged. We also obtained referral source for all samples and clinical details for abnormal samples. Six hundred and seventy-one coagulation requests were received during the study period. Three hundred and eighteen of 671 (47.4%) coagulation requests were for monitoring of anticoagulation. Three hundred and fifty-three of 671 (52.6%) requests were for coagulation screening rather than anticoagulant monitoring. In the coagulation screens received, PT was prolonged in 19 of 353 (5.4%). PT was longer than 20 s in four of 353 cases (1.1%). APTT was prolonged in 19 of 353 (5.4%). APTT was longer than 50 s in four of 353 (1.1%). No patients with abnormal PT or APTT had any bleeding sequelae during the study period. Unregulated coagulation screening has a low yield of abnormal results; the majority of these abnormal results show mild prolongation of PT or APTT with no evidence that they are associated with an increased bleeding risk.
    • An assessment tool for acutely ill medical patients.

      Gleeson, Margaret; Kellett, John; Cowan, Mairead; Casey, Marie; Mid-Western Regional Hospital, Nenagh, County Tipperary, Ireland. (2012-01-31)
      This article reports the implementation and impact of a standardized systematic evidence-based predictive score for the initial assessment of acutely ill medical patients. The Simple Clinical Score (SCS) was introduced in the A&E department and the medical floor of the authors' hospital between June 2007 and July 2008. The SCS was well received by the staff - 67% felt it greatly improved patient assessment and was very valuable for ensuring appropriate placement of the patient after admission and improved the quality of care. This article describes the change process, the pilot evaluation and the training programme undertaken during the implementation of the SCS. It is hoped that this experience will be of value to other project teams who are undertaking similar initiatives.
    • An audit of AE referrals to fracture clinics at the University Hospital Limerick

      East, JM; Whittemore, K; Polan, M; O’Daly, B; Lenehan, B (Irish Medical Journal (IMJ), 2014-02)
      101 consecutive patients referred from the A&E to UHL orthopaedics fracture clinics between September and October 2012 were retrospectively included. A retrospective chart review was conducted. Reason for referral, physicianâ s level, diagnosis in clinic and intervention were recorded. True positives (TP) were referrals requiring orthopaedic follow-up or treatment. False negatives (FN) were referrals requiring no follow-up from the orthopaedic services. Positive predictive values (PPV) were calculated from these values.
    • An audit of the management of thyroid disease in children with Down syndrome

      King, K; O' Gorman, CS; Gallagher, S (2014)
      Children with Down syndrome are at a higher risk of thyroid dysfunction than children in the general population. The aim of this audit was to determine thyroid screening practice at University Hospital Limerick and to compare it to the Irish guidelines for the medical management of children with Down syndrome. The thyroid function tests (TFT) of 148 children with Down syndrome were assessed through retrospective database review. Overall compliance with the guidelines was 79/148 (53%), although this varied by age category. The 0-5 years category had a compliance rate of 47/54 (87%), the 6-11 years category was 22/51 (43%), and the 12-17 years category had a compliance rate of 10/43 (23%). The guidelines are effective for monitoring purposes, although performing an annual TFT throughout childhood may be warranted.
    • Bed Utilisation in an Irish Regional Paediatric Unit A Cross-Sectional Study Using the Paediatric Appropriateness Evaluation Protocol (PAEP)

      Ó hAiseadha, Coilín; Mannix, Mai; Saunders, Jean; Philip, Roy K. (Int J Health Policy Manag, 2016-05)
      Increasing demand for limited healthcare resources raises questions about appropriate use of inpatient beds. In the first paediatric bed utilisation study at a regional university centre in Ireland, we conducted a cross-sectional study to audit the utilisation of inpatient beds at the Regional Paediatric Unit (RPU) in University Hospital Limerick (UHL), Limerick, Ireland and also examined hospital activity data, to make recommendations for optimal use of inpatient resources.
    • Bereavement Counselling for Healthcare Workers in the Aftermath of Child Death

      O’Sullivan, D; Stone, G; Mahomed, H; O’Reilly, P; Stewart, P; Noonan, H; Murphy, A.M (Irish Medical Journal, 2019-05)
      To assess the views and experiences of bereavement counselling services among healthcare staff dealing with paediatric ward death at UHL.
    • Caffeine Treatment for Apnea of Prematurity and the Influence on Dose-Dependent Postnatal Weight Gain Observed Over 15 Years.

      Philip, Roy K; Ismail, Abu; Murphy, Bernadette; Mirza, Adnan; Quinn, Collette; Dunworth, Margo; University Hospital Limerick (Journal of Caffeine and Adenosine Research, 2018-09-01)
      To analyze the influence on weight gain of infants exposed to two dosage regimens of oral caffeine citrate (CC) for apnea of prematurity.
    • Can augmentation index be used as an accurate tool in the diagnosis of peripheral obstructive arterial disease?

      Coyle, P; Duff, G; Gavin, O; Clarke Moloney, M; Burke, P E; Kavanagh, E G; Grace, P A; Mid Western Regional Hospital Limerick, Limerick, Ireland. petecoyle@gmail.com (2012-09)
      The use of radial augmentation index (rAI) as an indicator of vascular disease was investigated in the vascular imaging laboratory in a regional hospital.
    • Can mean platelet component be used as an index of platelet activity in stable coronary artery disease?

      Cooke, John; Murphy, Tracy; McFadden, Eugene; O'Reilly, Mairead; Cahill, Mary R; Mid-Western Regional Hospital, Dooradoyle, Limerick, Ireland. (2012-01-31)
      Acute coronary syndrome is associated with intracoronary thrombosis secondary to platelet activation. Previous groups have investigated platelet activation in both stable and unstable vascular disease. Most measures of platelet activation are not routinely available or easily adaptable to large scale clinical use. Recently, measurement of the mean platelet component (MPC) has become part of the routine data provided by an automated full blood count analyser, the Advia 120. MPC measures platelet density which changes on platelet activation. Our objectives were to determine if platelet activation, as measured by MPC, is increased in patients with stable coronary artery disease (CAD) and to determine if MPC could be useful in differentiating people with stable CAD from controls on an everyday clinical basis. Three hundred and forty-five consecutive patients attending for elective coronary angiography had full blood count analysis and MPC measurement performed using an ADVIA-120 analyser. Three hundred and twenty-four were analysed in our final dataset. Two hundred and fifty-three (78%) had CAD. Patients with CAD were significantly (p<0.001) older than those without (63.8 versus 56.0 years). Results failed to demonstrate a difference (p=0.467) in MPC between patients with CAD and those with normal coronary arteries (25.8 versus 26.0). Likewise, there was no correlation between MPC and the severity of CAD (Kendall's tau b=-0.086, p=0.04). MPC is not a useful index of platelet activity in stable CAD when used in everyday clinical practice.